Psychological Reactions to Combat; 12+ Years into the Long War

1. Psychological Reactions to Combat; 12+ Years into the Long War COL (Ret) Elspeth Cameron Ritchie, MD, MPH Chief Clinical Officer Department of Behavioral Health Washington DC Elspeth.Ritchie@dc.gov Elspeth.Ritchie@us.army.mil

2. OUTLINE • Background and History • 9/11 at the Pentagon • Post-Traumatic Stress Disorder • Suicide in the Army • Complementary and Alternative Medicine for PTSD • Including dogs! • Veterans and the Public Mental Health System • Way Ahead

3. A Brief History of Psychological Reactions to War • World War I--“shell shock”, over evacuation led to chronic psychiatric conditions • World War II--ineffective pre-screening, “battle fatigue”, lessons relearned, 3 hots and a cot • The Korean War---initial high rates of psychiatric casualties, then dramatic decrease Principles of “PIES” (proximity, immediacy, expectancy, simplicity) • Vietnam • Drug and alcohol use, misconduct • Post Traumatic Stress Disorder identified later • Desert Storm/Shield • “Persian Gulf illnesses”, medically unexplained physical symptoms • Operations Other than War (OOTW) • Combat and Operational Stress Control, routine front line mental health treatment

4. 9/11 in Washington DC • Beautiful clear fall day • New York attack • Pentagon burning • Reports of bombs elsewhere • Are We at War?

5. Combat Stress Control Principles Applied • Proximity, Immediacy, Expectancy. Simplicity • DiLorenzo Clinic at the Pentagon • Army, Air Force, Navy personnel operations for medical and mental health services • -Groups • People more open to talk in workplace or at ‘coffee rounds”

6. Development of A Sustained Response • Family Assistance Center • Operation Solace

7. The Pentagon Family Assistance Center • Tended to families of all victims • The Sheraton in Crystal City • Extended family, children • Most lived there for up to a month • Services • Informational briefings • Red Cross • Department of Justice, FBI • Counseling • Childcare • recreation • Medical care • DNA collection

8. The Pentagon Memorial at the Dedication -

9. Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Numerous stressors Multiple and extended deployments Battlefield stressors IEDs, ambushes, severe sleep deprivation, Medical Severely wounded Soldiers, injured children, detainees Changing sense of mission Strong support of American people for Soldiers Major Focus of senior Army Staff Numerous new programs developed to support Soldiers and Families

10. The Army since 9/11 • Volunteer Army • Know they are going to war • Seasoned, fatigued • Large Reserve Component • Reserve, National Guard • Elevated suicide rate • Wounded Soldiers • Effects on Families • Continuous deployments • Families of deceased • Families of wounded • Difficult Economy • Recruiting now easier

11. Range of Deployment-Related Stress Reactions Mild to moderate Combat Stress and Operational Stress Reactions (Acute) Post-traumatic stress (PTS) or disorder (PTSD) Symptoms such as irritability, bad dreams, sleeplessness Family / Relationship / Behavioral difficulties Alcohol abuse “Compassion fatigue” or provider fatigue Suicidal behaviors Moderate to severe Increased risk taking behavior leading to accidents Depression Alcohol dependence Completed suicides

12. PTSD DSM IV Diagnostic Concept Traumatic experience leads to: Threat of death/serious injury Intense fear, helplessness or horror Symptoms (3 main types) Reexperiencing the trauma (flashbacks, intrusive thoughts) Numbing & avoidance (social isolation) Physiologic arousal (“fight or flight”) Which may cause impairment in Social or occupational functioning Persistence of symptoms mTBI may be associated with PTSD, especially in the context of Blast or other weapons injury

13. DSM 5 Definition of PTSD • Removes Criterion A-2 • Additional criteria • Somatic reactions • Sleep • Depressive symptoms • Anger and irritability

14. Evidence Based Approaches for PTSD • Psychotherapy • Cognitive behavioral therapy • Cognitive processing therapy • Prolonged exposure • Pharmacotherapy • SSRIs

15. New and Innovative Approaches • Other Pharmacotherapies • 2nd Generation Antipsychotics • Integrative therapies • Acupuncture • Stellate ganglion block • Yoga • Canine therapy • Technology • Virtual reality

17. Suicide Rates from 1990-2009 Army rate projected to Exceed U.S. population rate** **Comparable civilian rates were only available from 1990-2006 17

18. DoD Suicide Deaths/Rates Branch CY 2001-2010 1st Qtr

19. Risk Factors for Suicide in Army Personnel • Major Psychiatric Illness Not a Significant Contributor • Adjustment disorders, substance abuse common • Relationships • Legal/Occupational Problems • Substance Abuse • Pain/Disability • Weapons • 70% with firearm • Recent Trends • Older, higher rank, more females

20. The Department of Defense has mandated annual and post-deployment screening for PTSD and depression Post-deployment Health Assessment (PDHA): Conducted within 30 days of service members returning from deployment (begun 1998, s/p first Gulf War) Post-deployment Health Re-assessment (PDHRA): Conducted within 3-6 months for service members returning from deployment (began 2005 in Army) Periodic Health Assessment (PHA): Conducted annually (2009) Screening is based on an interview with a behavioral health care provider using a standardized interview guide. Service members at risk will received immediate intervention or a mental health referral. Screening and Surveillance Annual and Post Deployment Screens

21. Screening and SurveillanceThe DoD Suicide Event Report The Department of Defense implemented the DoD Suicide Event Report (DoDSER) based on the Army Suicide Event Report (ASER), which was validated by the U.S. Army Medical Research and Materiel Command. DoDSERs are submitted for suicide behaviors that result in death, hospitalization or evacuation from theater. Data collected from standardized records (e.g., medical records, CID). Army DoDSERs due w/in 60–days. Objective, detailed, and standardized information collected: Comprehensive data (method, location, fatality) Extensive risk factor data Dispositional or personal Historical or developmental Contextual or situational Clinical or symptom factors

22. Past Suicide Mitigation Approaches 22 • Analysis of Incident Suicides • DOD Suicide Event Report (DODSER) • Epidemiologic Consultations (EPICONS) • Clinical interventions to identify and treat high risk individuals • Training Soldiers, Leaders and Family Members to recognize and respond • ASSIST • ACE • Battlemind • Beyond the Front • Stand-Down Training

23. Suicide Risk Assessment Behavioral health care providers and key unit members play an active role in the management and treatment of suicidal Soldiers. • Improve suicide assessment and evaluation (primary care, behavioral health clinic, VA). • Establish best clinical practices and standards of care • Train behavioral health and medical care providers at all levels • Conduct routine reviews and audits to ensure compliance • Improve engagement and retention in behavioral health care employing motivational interviewing techniques. • Involve close family members and friends where ever possible. • Inform and educate unit leaders as appropriate. • Enhanced focus on postvention efforts (maintain vigilance post crisis), including cases of completed suicides.

24. Evidence-Based Treatments Adapt evidence-based treatments for suicidality among Soldiers. • Two generally accepted psychotherapeutic approaches for treating suicidal patients: • Cognitive behavioral therapy (based on social learning theory that focuses on changing distorted beliefs and cognitions about self and the world). • Dialectical behavioral therapy (a cognitive behavioral approach that includes social skills and problem solving). • Treat the underlying behavioral health disorder.

25. Population-Based Strategies for Suicide Mitigation 25 The best evidence-based suicide mitigation strategies are optimal identification of high-risk groups and treatment of suicidal individuals “Gatekeeper” strategies, which identify high risk individuals, may decrease suicides if identification leads to appropriate clinical management or reduction of stress Recent literature suggests interventions which decrease risk-factors in the population may impact suicide rates Current Army suicide mitigation programs focus on identification/treatment of high risk individuals, not groups. Incorporating strategies to mitigate risk-factors in the general Army population and among specific high risk groups may decrease risk for suicide in the population

26. Causal Factors for Violence Among Soldiers Percentage of Population Individual, Unit, and Environment Factors Very Low Risk Lower Risk Average Risk Higher Risk Very High Risk Number / Severity of Risk Factors • Multiple individual, unit, and community factors appear to have converged to shift the population risk to the right Facts Individual • Criminality/Misconduct • Alcohol / Drugs • BH Issues (untreated/under-treated) Unit • Turnover • Leadership (Stigma) • Training / Skills Environment • Turbulence • Family Stress / Deployment • Community • Stigma

27. Strategies to Decrease Violence • While it is important to identify and help individual Soldiers, the biggest impact will come from programs that shift the overall population risk back to the left • Effective medical treatment can prevent individuals from increasing in risk or decrease their risk, but it cannot shift overall population risk very much Army Campaign Plan: • Health Promotion, Risk Reduction, and Suicide Prevention • Increase Resiliency • Decrease Alcohol/Drug Abuse • Decrease Untreated/Undertreated BH • Decrease Stigma to Seeking Care • Decrease Relationship/Family Problems • Decrease Legal/Financial Issues Installation: • Reintegration (Plus) • Mobile Behavioral Health Teams • Mental Toughness Training • Resiliency Training • Military Family Life Consultants • Decompression Reintegration • Warrior Adventure Quest • Consistent Stigma Reduction themes Percentage of Population Population Interventions Very Low Risk Lower Risk Average Risk Higher Risk Very High Risk Number / Severity of Risk Factors

28. Selected Dog ProgramsSupplement Traditional Rehabilitation/Therapy Programs • Animal Assisted Activities • Animal Assisted Therapy • Specialized Facility Canines • Military Therapy Dogs • Combat Stress Units • Walter Reed • Warrior Transition Battalion Work and Education Programs • Service dog training • Paws for Purple Hearts • Dog behavior/obedience and care training • Washington Humane Society Canine Assisted Therapy and Army Medicine AMEDD Journal April to June 2012

29. How training service dogs addresses PTSD symptoms PTSD Symptom Clusters • Re-experiencing (B) • Avoidance and Numbing (C) • Increased Arousal (D)

30. Re-experiencing symptoms *Grounding in the here and now* • Train dog to have positive associations w/noises etc. • Dogs have the ability to redirect through touch • Changing the context; “I didn’t have a dog in Iraq” • Lower anxiety when triggered -

31. Avoidance and numbing symptoms Avoidance • Need to socialize service dogs in the community • Dogs serve as social lubricants. Isolation is not an option. • Dogs require a daily schedule, a reason to wake up • Participate in a meaningful activity, pos. sense of purpose Numbing • Need to use positive emotions to reinforce behaviors • Fake it until you make it • Mindfulness, living in the moment, affective domain • Learning effective communication skills, assertiveness

32. Symptoms of increased arousal • Concentrate on dog’s training, not self survival • Practice emotional regulation w/ commands & praise • Sleep comfort • Opportunity to practice patience experientially • Learn to synchronize with low aroused dogs

33. Training also impacts behaviors/symptoms that are common for Warriors but may not be part of diagnostic criteria. Parenting skills Pain management Trust issues Grief and loss issues

34. The Public Mental Health System and Veterans

35. “State Example” Washington DC

36. WASHINGTON, DCunique characteristics • A Tale of Two Cities • Home to Very High Income and Very Low Income • Very Transient residents and multi-generational families • “City-State” - Collapsed Political Structure • State and local functions; Mayor is Governor, City Council is State Legislature • Federal and Local Governments Co-Exist • Relatively stable economy • Small tax base (federal buildings, universities, hospitals, nonprofit organizations) • Under the Thumb of Congress • No vote in Congress, no 10th amendment protection • No legislative or budget autonomy • DC National Guard only activated by the President • Geographically Condensed • All urban, height restrictions on buildings • 19 hospitals, 19 nursing homes, but no state prison

37. Washington, DCa magnet • Both home-grown and transient consumers • Consumers come to DC for a variety of reasons: • Some believe there are lots of jobs • Some believe there are better services • It’s easy to establish residency • “Right to shelter” - access to housing for the homeless • “Someone put me on the bus to come here” • Anger at government • Perceived access to the government • Monuments and free museums • In love with the First Lady

39. Homeless Veterans Veterans are 12% of the adult homeless in Wash DC 2/3rds are chronically homeless 30% have histories of substance abuse 28% mental health conditions

40. Relationship Between DBH, the VA and the Military

41. Overall themes • Disconnects between Department of Veterans Affairs system, military, academics and public mental health system • At least in Washington DC • Military residents rotate through CPEP (the Psych ER for DC) • Residents from academic institutions rotate through VA • Disconnects between programs and psychiatric societies and state mental system • SAMHSA Policy Academy attempting to improve • Economic security • Health care • Homelessness • Education • Criminal justice

42. VA in Washington DC • Hospital in Wash DC serves National Capital Region (NCR) • Homeless outreach • Supported employment • Various residential/nursing facilities outside region • “Central” VA in downtown DC • Vet Centers

43. Military in and around Wash DCWalter Reed Army Medical Center—closed

44. Walter Reed National Military Center—in Bethesda

45. Pentagon

46. Other Military Facilities in the NCR • Andrews Joint Base • Bolling Joint Base • Ft Belvoir with new community hospital • Quantico Marine Base • Ft Meade • Defense Center of Excellence • National Intrepid Center of Excellence

47. Current Efforts in Collaboration • Getting patients into systems of care and supported employment • Combined homeless outreach meetings • Asking question at Access Help Line “Are you a veteran?” • Office of the Attorney General teaching VA on commitments, involuntary hospitalization, etc. • Discussing with psychiatric societies • Training police on working with veterans

48. Veterans Courts 80 veterans courts

49. Schools and Veterans Increasing number of Veterans organizations in schools

50. Future efforts • Greater interaction of VA, military, public mental health, academic medicine • More organized community supports for returning veterans • More integrations for return home efforts